States and health systems activate crisis standards, new protocols as omicron strains U.S hospitals

Multiple states have in recent days adopted new protocols and taken aggressive steps to help overwhelmed hospitals grapple with yet another onslaught of patients fueled by the highly contagious omicron variant. From halting elective surgeries, to curtailing the number of nurses caring for patients, or using emergency services to transport the most severe cases to hospitals, these new actions are intended to triage care for those most in need and maximize use of limited resources.

Colorado, for instance, reactivated Friday crisis standards for emergency medical services for the second time during the pandemic, allowing ambulances to transport only the most severe cases to hospitals, among other measures. New York’s state health department Saturday said 40 hospitals would have to stop certain surgeries amid high caseloads and dwindling facility capacity. Both moves came after several hospitals in Maryland in recent weeks moved to crisis mode, implementing special protocols that give them more flexibility to delay some non-urgent surgical procedures to preserve bed capacity.

Oregon officials, too, are bracing for the worst, issuing guidelines that can help decide which patients get critical care if hospital capacity reaches a breaking point.

“High call volumes and staffing shortages are putting significant strain on the system,” Eric France, chief medical officer of the Colorado Department of Public Health and Environment, wrote in a letter activating the crisis-mode EMS protocols. State officials noted staff shortages because of sick workers and high demand for patient transports.

The moves come as the number of Americans hospitalized with covid-19 reached more than 126,000 over the past week, the highest level in a year. And hospital workers are more stretched than they’ve been during the crisis, with nearly a quarter of medical centers reporting recently they have a “critical” staffing shortage, according to some accounts.

Colorado’s crisis standards activation focuses on EMS - including ambulance and paramedic services - “because the pinch points are largely not in the ICU, which is what we were worried about previously,” said Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.

He said ICUs are still full and regular hospital floor beds are “bursting at the seams,” as people stream into emergency departments. But not all who arrive are true emergencies. Many are also coming in seeking a coronavirus test, for example, because they can’t find one elsewhere. The activated protocols mean responders can assess patient needs before taking them to the hospital.

“What’s changed is EMS can now come and say, ‘You know, we’d normally bring you into the emergency department, but you don’t meet the criteria given the current surge,’ " said Wynia, who helped Colorado write its crisis standards of care early in the pandemic.

Patients with less-urgent needs may be taken to urgent-care centers and other alternative sites when appropriate, according to the guidelines. The state health department noted crisis standards have not been activated for hospitals at this time and urged patients to continue to seek emergency care as they normally would.

“Your health in an emergency is always a priority,” France said. “The dispatchers and emergency medical service experts will help you determine if you need immediate care.”

Health officials have found this wave of the pandemic is distinct from previous surges, with a majority of patients at some hospitals being admitted for reasons other than covid, only to have infections discovered after arrival.

“When you’re testing everyone and you’ve got an omicron variant, which often will cause relatively mild illness or no illness . . . you’ll find a bunch of people who have incidental cases of covid but that’s not what they came in for. It was their sprained ankle,” Wynia added.

As of Friday, 94% of Colorado’s hospital beds for acute care were in use, and across the state, more than half of facilities are anticipating staff shortages within the next week, according to the state’s coronavirus dashboard. Covid-related hospitalizations rose 21% in the past week in Colorado, according to data tracked by The Washington Post.

In Maryland, as patient volumes surge, several hospitals have moved to crisis mode. At least six hospitals from the University of Maryland Medical System network have implemented crisis standards of care in the past two weeks, including the university’s Baltimore Washington Medical Center.

St. Joseph Medical Center, in Towson, another hospital in the network, announced it was moving to crisis mode last week, arguing the high demand for care was “far outpacing” the hospital’s available resources, according to a statement.

The hospital’s chief medical officer, Gail Cunningham, said they have seen a “massive attrition of health workers” over the past year which led them to face the omicron surge severely understaffed.

She pointed at several various factors that have left the hospital stretched thin: high number of infections among staff putting workers out of work for days, many female workers leaving to home-school their children, or some quitting jobs suffering severe burnout. Others, have taken top-dollar jobs at other agencies, she said.

“We had this perfect storm of high volumes and very low staffing,” Cunningham said in an interview Monday.

The new protocols include a change to nursing ratios, from a an average of one nurse for four patients, to one for every six or seven patients now. The hospital is treating patients in areas they would not usually, like the recovery room. It has also canceled all non-urgent surgeries and deployed a surgical team to support the emergency department and other floors where they are needed, Cunningham said.

Johns Hopkins Bayview Medical Center in Baltimore also recently announced it would begin implementing crisis-care protocols as executives said the hospital was seeing clinical care demand for covid and non-covid patients “spike dramatically in recent days,” according to Kevin Sowers, president of the Johns Hopkins Health System.

“This decision was not taken lightly,” Sowers said in a news release, adding that the pandemic has continued to “critically” stress all six network hospitals.

Some of the changes for these Maryland hospitals give them greater flexibility to streamline processes, delay some surgical procedures to preserve bed capacity and redeploy staff or rapidly move them between departments according to needs.

And while the changes are intended to give hospitals the capacity to operate more effectively under pressing circumstances, Cunningham admitted the protocols also come with some risks and are far from being an ideal situation.

“There is an increased likelihood of error, whether it is a medical administration or labeling error, there is risk for that,” she said, referring to nurses who, she said, are now spending less time with patients.

The crisis standards have been a feature of earlier pandemic surges: Last fall, they were activated in some states and hospital systems that were nearing breaking points.

Back in November, the two largest hospital systems in Albuquerque, activated crisis standards of care citing an “unsustainable and unprecedented level of activity,” in terms of space and staffing because of rising covid hospitalizations.

Other states such as Oregon are preparing for a worst-case scenario, too. On Friday, the Oregon Health Authority published new directions for hospitals that outline a point system, or “triage priority score,” to rank patients who would get access to critical care in the event of exceeded capacity - based on the person’s likelihood to survive to hospital discharge.

In New York, there has been a 57% increase in hospitalizations in the past week, according to data tracked by The Washington Post.

“We will use every available tool to help ensure that hospitals can manage the covid-19 winter surge,” said acting state health commissioner Mary Bassett at a Saturday news conference.

“We cannot return to the early months of the pandemic when hospitals were overwhelmed,” she added, urging the public to get vaccinated and boosted to “protect the hospital system.”

In Colorado, as it is across the country, Wynia said a lot of health workers are out sick, which is partly fueling the strain. On top of that, people are streaming into hospitals who may have been delaying care.

“We’ve now got people who have been putting things off for the last two years,” he said. “But they have pain in their knees and they can’t stand it anymore.”

If there’s a silver lining, he said, it’s the way the virus and its variants have forced new conversations about resource shortages, and brought more people, including the public, into those discussions.

“We are seeing multiple versions of resource shortages that are hopefully teaching us something when we have less-extreme shortages in the future,” he said.